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Showing results for "lessons learned".

1261. A Strategic Approach for Funding Research: The Agency for Healthcare Research and Quality’s Patient Safety Initiative 2000–2004 (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Keyes.pdf
      January 01, 2004 - Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems.

1262. The Association Between Pharmacist Support and Voluntary Reporting of Medication Errors: An Analysis of MEDMARX® Data (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety-2/vol1/Advances-Jones_91.pdf
      July 17, 2008 - HROs pay attention to near misses as small failures that provide free lessons about sources of poor

1263. Measures of Implementation of Person-Centered Care Planning for People with Multiple Chronic Conditions (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/mcc/pccp4p/measures-rapid-scan-report.pdf
      April 10, 2025 - Measuring patient well-being during whole- person clinical care: Lessons from the veterans health administration … and why this interview is important is to learn more from you about what you know and what you have learned … I have learned a lot from our conversation today.

1264. Clinical Inertia and Outpatient Medical Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/OConnor.pdf
      January 01, 2003 - Lessons from experienced guideline implementers: attend to many factors and use multiple strategies

1265. Final Progress Report: APPLIED STRATEGIES FOR IMPROVING PATIENT SAFETY (ASIPS) (pdf file)
      www.ahrq.gov/sites/default/files/2024-02/pace-report.pdf
      January 01, 2024 - Our mixed-methods approach allowed us to efficiently and effectively extract patient safety lessons

1266. Final Progress Report: Safety in the Home Healthcare Sector: A Pilot Study (pdf file)
      www.ahrq.gov/sites/default/files/2024-11/gershon-report.pdf
      January 01, 2024 - .8 This approach, referred to by Leape and Berwick as a “mantra in healthcare,” is based in part on lessons … learned from high-hazard work organizations, or “high-reliability organizations” (HRO), such as aviation … Five Years After To Err is Human: What Have We Learned? JAMA. 2005;293(19):2384-2390. 10. … Organizational failure: lessons from industry applied to the medical domain.

1267. Accurate ADHD Diagnosis (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-088-fullreport.pdf
      January 05, 2017 - Additionally, the team learned valuable information about the nature of the documentation of the relevant … Lessons from Use of the Measure 1. … What lessons are available from the current or prior use of the measure? … Lessons from Use of the Measure Section 9. Levels of Aggregation Section 10.

1268. Environmental Scan of Patient Safety Education and Training Programs (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/research/findings/final-reports/environmental-scan-programs/envptscan.pdf
      June 01, 2013 - Upon contacting these organizations, we learned that the QIOs were in a transition period between the … Next Steps Based on the lessons learned throughout this project, AIR recommends that AHRQ consider

1269. Final Progress Report: Reducing Diagnostic Errors in Primary Care Pediatrics (pdf file)
      www.ahrq.gov/sites/default/files/2025-03/rinke-report.pdf
      January 01, 2025 - Lessons from this project can be applied broadly and serve as a foundation for hypertension care delivery … After completing baseline data collection, teams participated in a 2-day video conference, where they learned

1270. Part Two: Design of Physician Feedback Reporting Systems | Agency for Healthcare Research and Quality
      www.ahrq.gov/ncepcr/tools/confid-report/system-design.html
      February 01, 2016 - Performance improvement messaging for physicians: lessons from market research* Just

1271. Final Report: Using Risk Models To Improve Safety With Dispensing High-Alert Medications in Community Pharmacies (pdf file)
      www.ahrq.gov/sites/default/files/2024-01/cohen-report.pdf
      January 01, 2024 - not be practical for every community pharmacy to conduct its own ST-PRA modeling, application of the lessons … learned from these existing models can lead to widespread improvement in community pharmacies nationwide … Lessons learned and actions needed. Professional Safety. … On error management: lessons from aviation. BMJ. 2000;320(7237):781-785. 54 Van der Schaaf TW.

1272. AHRQ-Funded Patient Safety Project Highlights (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/patient-safety/highlights/ps-project-highlights-harms.pdf
      August 01, 2025 - This revision reflects important changes in the environment, new guidelines and lessons learned, such … In earlier reporting systems, data was not timely, delaying knowledge learned from the reports.

1273. Low Tidal Volume Ventilation Guide for Reducing Ventilator-Associated Events in Mechanically Ventilated Patients (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ltvv-mvpguide.pdf
      January 01, 2017 - Mechanical ventilation: Lessons from the ARDSNet trial. Respir Res. 2000 ;1(2):73-7. … What have we learned about interventions to reduce medical errors?

1274. Final Progress Report: Patient Partnerships To Improve Safety in the Clinic Setting: Creating an accurate medication list through a patient-centered approach (pdf file)
      www.ahrq.gov/sites/default/files/2024-07/leonhardt-report.pdf
      January 01, 2024 - impact of the project on patients, providers, council members, and the community • Disseminate the lessons … learned from the project, including tools and interventions that were effective in improving the accuracy

1275. Paul Tedrick (doc file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/cauti-tools/archived-webinars/mindfulness-transcript.doc
      June 10, 2014 - And this is a lesson I think we’ve learned from infection control and a lesson that we’ve learned from

1276. Mindfulness: Engaging Frontline Providers in Antimicrobial Stewardship (June 10, 2014) | Agency for Healthcare Research and Quality
      www.ahrq.gov/hai/cauti-tools/archived-webinars/mindfulness-transcript.html
      December 01, 2017 - And this is a lesson I think we've learned from infection control and a lesson that we've learned from

1277. A Conceptual Model for Disclosure of Medical Errors (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol2/Fein.pdf
      January 01, 2004 - A nurse felt similarly and relayed, “I learned how to discuss grief and loss… But error? … Reporting and preventing medical mishaps: lessons from nonmedical near miss reporting systems.

1278. Findings | Agency for Healthcare Research and Quality
      www.ahrq.gov/research/findings/final-reports/ptfamilyscan/ptfamily3.html
      July 01, 2018 - Generally, this evidence represents lessons learned from the larger body of literature on patients' and

1279. A Study of Adverse Occurrences and Major Functional Impairment Following Surgery (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol1/Rojas.pdf
      March 15, 2004 - The abstraction instrument was modified on the basis of lessons learned in the pilot abstraction.

1280. Serious Reportable Adverse Events in Health Care (pdf file)
      www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/patient-safety-resources/resources/advances-in-patient-safety/vol4/Kizer2.pdf
      December 01, 2000 - serious reportable events from multiple health care organizations can be used to improve safety if the lessons … learned from their investigations of the underlying system problems and/or failures are disseminated